HSE Tobacco Free Ireland Programme - HSE Tobacco Free Ireland Programme Implementation Plan 2018-2021

HSE Tobacco Free Ireland Programme - HSE Tobacco Free Ireland Programme Implementation Plan 2018-2021
HSE Tobacco Free
Ireland Programme
HSE Tobacco Free Ireland Programme
Implementation Plan 2018-2021
HSE Tobacco Free Ireland Programme - HSE Tobacco Free Ireland Programme Implementation Plan 2018-2021
HSE Tobacco Free Ireland Programme - HSE Tobacco Free Ireland Programme Implementation Plan 2018-2021
HSE Tobacco Free Ireland Programme

Table of Contents
Glossary                                                   X
Foreword                                                   X
Introduction                                               X
Context for Action                                         X
Strategic Direction                                        X
Targets and Outcomes 2018-2021                             X

AND        Assistant National Director
CHO        Community Healthcare Organisation
CYPSC      Children & Young Peoples Services Committees
DoH        Department of Health
EH         Environmental Health
GNTH       Global Network of Tobacco Free Healthcare Services
HG         Hospital Group
HIQA       Health Information & Quality Authority
HP&I       Health Promotion and Improvement
HI         Healthy Ireland
HR         Human Resources
HSE        Health Service Executive
KPI        Key Performance Indicator
MH         Mental Health
MN-CMS     Maternal and Newborn Clinical Management System
NBSMS      National Behavioural Support Management System
NCEC       National Clinical Effectiveness Committee
NMBI       Nursing and Midwifery Board of Ireland
NSP        National Service Plan
SP&T       Strategic Planning & Transformation
TFC        Tobacco Free Campus
TFCP       Tobacco Free Campus Policy
TFI        Tobacco Free Ireland
TFIPG      Tobacco Free Ireland Programme Group
TUSLA      The Child and Family Agency (Tús Lá)

HSE Tobacco Free Ireland Programme - HSE Tobacco Free Ireland Programme Implementation Plan 2018-2021
HSE Tobacco Free Ireland Programme

    The HSE is committed, under Action 4.5 of the Health Service Reform in Healthy Ireland, to “establish
    multi-disciplinary national teams within Strategic Planning and Transformation to lead and take
    responsibility for policy priority areas such as Tobacco Control, Healthy Eating and Active Living (HEAL),
    Healthy Childhood, Alcohol, Wellbeing and Mental Health, Positive Aging and Sexual Health. The priority
    groups will ensure appropriate governance across the organisation for these areas and ensure that
    the priorities in the Healthy Ireland Implementation Plan are delivered effectively. The establishment of
    Hospital Groups and Community Healthcare Organisations (CHOs) and more recently the appointment
    of a Health and Wellbeing Head of Service to each of the CHO areas will facilitate the work of the
    Priority Programmes. This will help to ensure that Healthy Ireland (HI) priorities are delivered across the
    HSE through a collaborative approach which in turn will provide a more integrated service with better
    outcomes for service users.

    The main aim of the new Tobacco Free Ireland Programme is to take responsibility for and systematically
    drive policy priorities in the area of tobacco control across the HSE. Ms. Martina Blake has been appointed
    as lead to the Tobacco Free Ireland Programme.

HSE Tobacco Free Ireland Programme - HSE Tobacco Free Ireland Programme Implementation Plan 2018-2021
HSE Tobacco Free Ireland Programme

The Tobacco Free Ireland Policy Priority                 This national implementation plan (2018-2021)
Programme was established in late 2016 as                sets out the HSE strategic direction and priority
part of the Healthy Ireland in the Health Services       actions to achieve this.
Implementation Plan.1 It has a remit to:
                                                         The objectives of the Tobacco Free Ireland Policy
“mobilise the health services to                         Programme over the next four years are to:

improve health and wellbeing and                         â Prioritise the protection of children in all of our
play its part in the achievement                            initiatives and contribute to the denormalisation
                                                            of tobacco use for the next generation
of a reduction in smoking
prevalence to less than 5%                               â Support people to quit and treat tobacco
                                                            dependence as a health care issue
of the population by 2025”.
                                                         â Monitor, build and maintain compliance with
The Programme (Appendix A) works to coordinate
                                                            tobacco legislation
and lead tobacco control activity across the health
services to ensure implementation of the HSE
actions contained within the Government Tobacco
Free Ireland2 strategy.

1   Healthy Ireland in the Health Services National
    Implementation Plan 2015 – 2017, Health Service
    Executive, 2015.
2   Tobacco Free Ireland: Report of the Tobacco Policy
    Review Group, Department of Health, 2013.
HSE Tobacco Free Ireland Programme

    Context for Action

    Tobacco use is the leading cause of preventable         Tobacco related morbidity and mortality accounts
    death in Ireland with 5,800 smokers dying each          for over 200,000 hospital episodes annually with
    year from tobacco related diseases. Smoking             the total cost to the health service estimated to
    related deaths are mainly due to cancers, chronic       be over €460 million. The total estimated cost of
    obstructive pulmonary diseases (COPD) and               lost productivity is over €1 billion. This comprises
    heart disease. Cigarettes contain over 7000 toxic       productivity lost through smoking breaks, smokers
    chemicals, many of which are proven to cause            taking additional absence from work and the
    cancer. Smoking harms almost every organ of             premature death of employed workers. The largest
    the body, causing many different illnesses and          proportion of the lost productivity from smoking
    diseases. A long-term smoker has an average life        is estimated to be from the premature death of
    expectancy of approximately, 10 years less than         employed individuals.4
    a non-smoker. The younger you are when you
                                                            There is an ever increasing recognition among
    start smoking, the more likely you are to smoke
                                                            policy makers and health service managers/
    for longer and to die early from smoking.
                                                            service providers that we need to reorient our
    The Healthy Ireland Survey taken in 20173 reported      health services towards prevention of tobacco
    a smoking prevalence of 22%, 18% daily smokers          related chronic disease as these are the major
    and a further 4% occasional smokers. While we           drivers of healthcare costs.
    have seen a reduction in youth initiation from
    12.3% in 2010 to 8.3% in 2014 among the 10-17
    age group (ref) there is a high level of smoking
    among young adults with one in every three
    25-34 year olds currently smoking.

    3   Healthy Ireland Survey 2017: Summary of Findings,
        IPSOS MRBI, 2017.
    4   An Assessment of the Economic Cost of Smoking in
        Ireland, ICF International, 2016.
HSE Tobacco Free Ireland Programme

        Smoking in Ireland Statistics
         Smoking Prevalence
         (Ref: Healthy Ireland Survey 2017)

  22%                                                                                     27%
18% daily                                25%           VS     20%                        Ex-smokers
                                                                                       Ireland now has more
4% occasionally
                                                                                       quitters than smokers

         Prevalence by Age
         (Ref: Healthy Ireland Survey 2017)

         Age Category (Years)

    19%               34%               24%          21%      20%            16%

     15-24             25-34            35-44         45-54    55-64          65-75              75+

  *Worth noting that one in three 25-34 year olds.

         Daily Exposure to Second Hand Smoke
         (Ref: Healthy Ireland Survey 2017)

                 34%                                 10%                    16%

    Smokers                            Non-Smokers            Population are exposed to second
                                                              hand smoke on a daily basis

HSE Tobacco Free Ireland Programme

     Attitudes to Quitting
     (Ref: Healthy Ireland Survey 2017)
     (Ref: Youth Smoking in Ireland, 2018)
                                                                                      to quit

    â 57% of current smokers are                                          57%
      thinking about quitting                                             Thinking about quitting

    â Smoking rates are higher in more
                                                                         Thinking about
                                                   Not thinking          quitting but not
      deprived areas than more affluent                                                         Actively
                                                   about quitting        planning to
      ones. 32% of those living in the                                                          planning
      most deprived areas are current                                                           to quit
      smokers, compared to 16% of
      those living in most affluent areas

    â Current smokers were over 70%
      more likely to report distress
      indicative of probable mental
      health problems, compared to
      non-smokers, independent of
      age, gender and social class

    â 47% of all who have smoked in
      the past 12 months have made
      a quit attempt

     Interactions with Healthcare Professionals
     (Ref: Healthy Ireland Survey 2017)

     Discussed Smoking with a Healthcare
     Professional in the last year                                     Pharmacist


       35%                                Hospital Doctor
                                          25%                                               Other Healthcare

HSE Tobacco Free Ireland Programme

     Roll Your Own (RYO) Cigarettes
     (Ref: Roll Your Own Report, 2017)

                                                                      â Proportion of smokers using
                                                                         RYO cigarettes has increased
                                                                         from 3.5% in 2003 to 24.6% in

           3.5%                           24.6%                          2014.

                                                                      â Those under 25 years of age
                                                                         are three times more likely
                                                                         to smoke RYO cigarettes
                                                                         compared to those aged
                                                                         over 25.
            2003                              2014

      Age Group


                        23.9%        22.5%           24%
       Under 25           25-34       35-44           45-54              55-64             65+

     E-cigarette Usage
     (Ref: Healthy Ireland Survey 2017)

                    7%                                 7%
HSE Tobacco Free Ireland Programme

         Disease Burden
         (Ref: Nash et al. Literature Review) Tobacco Related Mortality

    of Death

                          44%                      30%                      25%                    1%
                          Cancers                  Cardiovascular           Respiratory            Digestive
                                                   Diseases                 Diseases               Diseases

          Financial Burden of Tobacco Use in Ireland
          (Ref: ICF Economic Assessment, 2016)

    €460m Health
          Service                       €1.6bn Exchequer                     €9bn          Loss of Welfare from
                                                                                           Morbidity & Mortality

    Cost to Health Services

          €171m                    €13m                  €15m                    €10m                 €256m
          Hospital                 Hospital              Hospital                Hospital             Primary Care
          Inpatient                Day Case              Outpatient              Emergency
          Admissions               Appointments          Appointments            Department

         Tobacco Free Ireland Strategy
         (Ref: Tobacco Free Ireland 2013)

                1                                  Five Key Areas                                        5
    Provide leadership – policy,
       practice and clinical
                                                      for Action                                  Monitor tobacco
                                                                                                 use and prevalence
                                                                                                  and evaluate the
                              2                                                            4       effectiveness of
                  Protect children through
                                                            3                        Treat tobacco interventions
                denormalisation of tobacco                                          dependence as a
                                                     Regulate the retail
               use and promotion of tobacco                                            care issue
                                                  environment and monitor
                     free environments             legislative compliance

HSE Tobacco Free Ireland Programme

 Determinants of Smoking
 A range of socio-demographic, environmental, behavioural and personal indicators predict the likelihood
 of adopting or rejecting smoking, particularly in early adolescence (90% of initiation to adult smoking
 commences in adolesence (ref)). A decision to smoke leads to trialling the behaviour, and the resulting
 experience is mediated by each of the three major streams of influence – the personal, the social setting
 and broader expectations and attitudes.


                   â Exposure to                                                                      â Adult smoking prevalence
                                             Tobacco environment

                                                                                    Community norms
                      tobacco marketing
                                                                                                      â Restrictions on smoking
                   â Images of smoking
                      in popular media
                                                                                                      â Attitudes to youth and
                                                                                                         youth culture
                   â Tobacco industry
                                                                                                      â Socio-economic and
                   â Access                                                                              cultural context
                   â Price

EXTRINSIC FACTORS                                                                                                           INTRINSIC FACTORS

             Family                                                                                                 Personal beliefs
             influences                                                First try                                    and values

 â Parental smoking                                                                                                         â No risk in trying
 â Sibling smoking                                                                                                          â It won’t happen to me
 â Parental values and                                             Experimentation                                          â Curiosity
    attitudes re
                                                                                                                            â Individual choice
                                                                                                                            â Adulthood aspirations
 â Socio-economic
                                          ‘Social’                                  Regular                                 â Perceptions of
                                          smoker                                    smoker                                       smoking norms
                                                                                                                            â Risk-taking propensity
                                                                                                                            â elf-esteem/self-image

             influences                                                                                             Personal
                                                                                                                    physiological factors

â Peer affiliations and                                               Resumption                                            â Genetics
    friendships                                                       of smoking
                                                                                                                            â In utero exposure
â Connectedness to
    school and/or home                                                                                                      â Puberty and
â Sense of alienation
                                             Adult                                  Adult
                                          non-smoker                               smoker

HSE Tobacco Free Ireland Programme

     Strategic Direction
     Improving the health and wellbeing of Ireland’s          support people to stay healthy and well, reduce
     population is a national priority and a key element      health inequalities and protect people from threats
     of healthcare reform. As part of this reform and         to their health & wellbeing. The vision is to support
     in response to an unsustainable level of chronic         every individual and sector of society to play their
     disease among our population, the Healthy                part in achieving a healthy Ireland through;
     Ireland (HI) Framework was adopted by the Irish
                                                              1. Reducing Chronic Disease – the biggest risk
     Government in October 2013. The Healthy Ireland
                                                                 to our population’s health and our services
     Framework draws on existing policies but proposes
     new arrangements to ensure effective co-                 2. System Reform – ensuring that we deliver
     operation, collaboration, to implement evidence-            the significant reforms which are underway
     based policies at government, sectoral, community           to support a better health system
     and local levels. It is about each individual            3. Staff Health and Wellbeing – ensuring we
     sector helping to improve health and wellbeing,             have a resilient and healthy workforce
     multiplying all efforts and delivering better results.
     It proposes a necessary shift towards a broader,
     more inclusive approach to governance for                Tobacco Free Ireland
     health, moving beyond the health service, across         National Policy
     national and local authorities, involving all sectors
     of society, and the people themselves. Healthy           The Department of Health published the Tobacco
     Ireland describes supportive mechanisms to               Free Ireland Policy in 2013 and is the successor to
     ensure effective co-operation between the health         the previous National Policy Towards a Tobacco Free
     sector and other areas of Government and public          Society. The policy sets out the plan for the future in
     services concerned with social protection, children,     achieving the goal of reducing smoking prevalence
     industry, food safety, education, transport, housing,    to less than 5% by 2025. It is estimated that in order
     agriculture and the environment.                         to achieve this target by 2025, in excess of 55,000
                                                              smokers will have to quit each year for the next
     The Health Service commitment to the delivery of         ten years5. The policy document makes sixty three
     Healthy Ireland is reflected in its Healthy Ireland      recommendations for cross governmental and non-
     Implementation Plans across the CHOs and
                                                              governmental organisations, including a number of
     Hospital Groups. The Strategic Planning and
                                                              recommendations for the health sector. It is about
     Transformation Office is responsible for driving this
                                                              each individual sector helping to improve health and
     agenda across the entire health service. There is
                                                              wellbeing, multiplying both our efforts and our results.
     an ongoing shift in focus towards a prevention
     agenda, where all services have a requirement to

HSE Tobacco Free Ireland Programme

Targets and Outcomes for the HSE Tobacco
Free Ireland Programme 2018-2021
It is recognised that achieving the population          This HSE Tobacco Free Ireland strategic
level outcomes and targets will be the result of        Implementation Plan acknowledges that it has a
the cumulative impact of the sixty three specified      role to play in the delivery of a Tobacco Free Ireland
actions in Tobacco Free Ireland. In this context, the   (
HSE Tobacco Free Ireland Programme

     Measureable outcomes
     The principle source of information is the Healthy Ireland Survey, which through repeated cross sectional survey of a representative sample
     of the population provides for tracking of smoking prevalence, quitting intentionality and quitting behaviour. It provides insights across
     key population groups, but is not useful for tracking at CHO or HG level. However, in relation to other areas and population groups, it
     should be noted that there are limitations to the existing routine information systems that are currently used to report on key aspects
     of the HSE Tobacco Free Ireland Programme Plan. Regarding smoking in pregnancy, there is currently no routine information system.
     The Growing Up In Ireland survey has some utility. A new maternity information system combined with a new behavioural management
     system will help. Likewise, smoking among people with mental health problems is not trackable through routine information.
     A comprehensive research programme and secondary analysis is useful in that regard and forms part of this programme plan.
      A sustained downward trend in the levels of tobacco use in the general population in children and young people, in pregnancy
      and those with Mental ill health.

      Overall Target 5% smoking prevalenace by 2025 as indicated in cross governmental TFI strategy. The HSE does not take
      responsibility for reaching the 5% target. It is envisaged however that the range of actions outlined within this strategy will
      contribute to an incremental reduction in smoking prevalence in support of the DOH goal for a Tobacco Free Ireland by 2025.

      Inputs                             Output Measures                    Outcome Measures                  Baseline (2017)
      QUIT campaign aimed at             Targeted, dynamic multi-media Decrease in prevalence of              22%
      overall population awareness       plan:                         tobacco use.
      and understanding of risks         Monitoring, evaluation and
      of tobacco and benefits of         tailoring of messaging, media
      quitting.                          and timing as required across
                                         search, social, digital and
                                         traditional media (including
                                         public relations)
                                                                            Increased website visits during   October/November 2017
                                                                            active media bursts. Clear        media burst resulted in 89%
                                                                            tracking of activity.             increase in sessions on QUIT.ie
                                                                            Omnibus and specific
                                                                            research on target audiences
                                                                            where required.
                                                                            Increase prevalence of positive   57% of smokers are at
                                                                            quit intentions.                  leastthinking about quitting
                                                                            Increase prevalence of quit       42% of current smokers have
                                                                            attempts particularly among       made a quit attempt in the
                                                                            men aged 25-44.                   past 12 months
                                                                            Ongoing measurement and           16,820 during 2017
                                                                            understanding of QUIT sign
                                                                            ups online.
                                                                            No. of clients who contact        2,914 during 2017
                                                                            QUIT Freephone.
                                                                            Visits to website.                245,430 during 2017
      Redevelopment of QUIT              Redevelopment of QUIT              Ongoing measurement
      website                            website in line with HSE digital   and understanding of user
                                         roadmap and to maximise            experience on QUIT.ie
                                         QUIT sign ups
                                         Closed Facebook groups             Signups to closed Facebook        To be piloted
                                         created, piloted, moderated        group and completion of
                                         and evaluated                      closed Facebook programme

HSE Tobacco Free Ireland Programme

Inputs                               Output Measures                    Outcome Measures                    Baseline (2017)
                                     Introduction of user feedback      No. of referrals to intensive       No existing data
                                     on QUIT.ie                         cessation support by health
                                                                        professionals annually
                                                                        No. of self-referrals to intensive No existing data
                                                                        cessation support
                                                                        No. of clients receiving            11,952
                                                                        intensive cessation support
                                                                        through HSE services
Brief intervention for               No. staff trained in MECC          No. of clients from specific
smoking cessation through            online modules.                    population groups receiving
implementation of Making             No. staff trained in skills to     intensive cessation support
Every Contact Count training         practice module                    through HSE services (Pregnant,
                                                                        those with mental ill health,
                                     No. non-HSE staff trained
                                                                        men, youth and low SES)
                                     No. undergrad health
                                                                        Increase proportion of clients      No existing data
                                     professional trainees trained
                                                                        who discussed a quit attempt
                                                                        with a healthcare professional
                                                                         to 40% for GPs                    35%
                                                                         to 35% for hospital doctors       25%
                                                                         to 25% for nurses                 22%
                                                                         to 20% for other health           12%
Development of clinical              Clinical guidelines developed,     Increase in no. smokers within      47% of all who have smoked
guidelines for the identification,   stakeholder consultation           the last 12 months who have         in the past 12 months have
diagnosis and treatment of           complete, guidelines endorsed      stopped smoking for one day         made an attempt to quit
tobacco dependence                   by Minister for Health and         or longer because they were
                                     published                          trying to quit
                                                                        Reduction in no. people who      18% daily smokers
                                                                        smoked tobacco products          4% occasional smokers
                                                                        daily and occasionally by
                                                                        0.5% prevalence per year
                                                                        (interdependent on DoH measures)
On-going implementation and          Implementation and on-going        TFC Policy implemented in   63% Mental Health Approved
monitoring of HSE Tobacco            monitoring of HSE Tobacco          100% Mental Health Approved Centres
Free Campus Policy in HSE            Free Campus Policy in 100%         Centres                     38% Mental Health Residential
services                             HSE services                                                   Centres
                                                                        100% Mental Health
                                                                        Residential Centres                 63% Older Persons Services
                                                                        100% Older Persons Services         49% Disabilities Services
                                                                        100% Disabilities Services          100% Primary Care Settings
                                                                        100% Primary Care settings
On-going monitoring and              No. test purchases carried out     % increase in compliance with       429 (90% compliance)
enforcement of tobacco                                                  sale of tobacco products to
legislation                                                             minors
                                     No. smoke free workplace            % increase in compliance with
                                     legislation inspections carried out smoke free workplace legislation
Youth Initiation and Prevalence                                         Reduction in no. children who       16%
                                                                        have tried smoking
                                                                        Reduction in no. children who       8.3%
                                                                        have tried smoking monthly or
                                                                        more frequently

HSE Tobacco Free Ireland Programme

     Actions, Measures and Deliverables
     Theme 1:
     Provide Leadership for the implementation of the HSE elements of Tobacco Free Ireland

              TFI Policy      Action Identified                                 Proposal for “HOW” this will be met

      1.1     1               Support effective implementation of the           Tobacco Free Ireland Priority Programme National
                              National Healthy Ireland and Tobacco Free         Implementation Group will identify & agree priorities
                              Ireland Action Plan (DoH) and ensure the          for National Service Plan/Operational plans and
                              Tobacco Free Ireland Programme priorities         support delivery of same across the CHOs and
                              are included in the National Service Plan         hospital groups.
                              and relevant annual operational Plans.

      1.2                     Develop a suite of Key Performance                Work with Strategic Planning and Transformation
                              Indicators to:                                    and the Performance and Planning Unit and service
                              a) Monitor impact of HSE delivered or             representatives to propose, review and quality
                                 funded interventions, programmes and           assure NSP, operational plans and KPIs. Examine
                                 services                                       existing tobacco related KPIs and develop new
                                                                                KPIs to monitor performance.
                              b) Monitor delivery of this Implementation
                                 plan                                           Engage with HI Governance group and HSE HI
                                                                                Office to support inclusion of and delivery of the
                                                                                TFI actions across the CHOs and Hospital groups.

      1.3                     Identify resource implications to deliver TFI     Draft annual PIDs for operational activities and new
                              actions contained within this plan.               projects based on programme.
                                                                                Prepare business cases and funding estimate bids
                                                                                and approve at TFIPG.

      1.4                     Engage with international health colleagues       Membership of the Global Network of Tobacco Free
                              to share learning and experiences in the          Healthcare Services (GNTH).
                              implementation of quality standards in
                              relation to tobacco management.                   Participation in Global Network conferences and
                                                                                Participation in development and hosting of World
                                                                                Conference on Tobacco and Health in 2021 with
                                                                                the DoH.

      1.5     10.1            Government Departments and state                  Ensure on-going engagement via: TACU within the
                              agencies including the Health Service             DOH, state agencies and NGOs and the Tobacco
                              Executive will continue to liaise and work with   Control Partners group.
                              non-governmental organisations in order to        On-going monitoring of cross governmental strategic
                              achieve policy aims set out in this plan.         public policy consultation processes.

HSE Tobacco Free Ireland Programme

Deliverables                                            Responsible                                   Time Frame
                                                                                               Commence     Complete

Annual priority actions and key performance             TFI Programme Team and TFIPG           2018         Annual
indicators identified and agreed and included in the                                                        2021
National Service Plan and relevant divisional service
operational plans.

Suite of KPIs identified.                               TFI Programme Team, HI lead, CHO/      2018         Annual
KPI review and monitoring sub group of TFIPG            Hospital Group representatives                      2021
Group established.
Annually agreed KPIs in NSP and Operational Plans.

TFI actions included in CHO and hospital group
Healthy Ireland plans.

PIDs drafted for all new tobacco activities annually.   TFI Programme Team                     2018         Annual
Annual funding estimates bid drafted and                                                                    2021
brought to Leadership/DoH through Planning
and Performance.

Participation in or coordination of International       TFI Programme Team                     2018         Annual
tobacco events to support the Tobacco Free                                                                  2021
Ireland agenda.
Participation in international research/events and
the GNTH to promote quality standards.

Partners group established under the Tobacco Free       TFI Programme Team                     2018         Annual
Ireland Programme.                                                                                          2021
Three annual meetings and on-going collaboration.
TFI Programme submits feedback to cross
governmental policy consultation processes to
embed tobacco control actions in future planning.

HSE Tobacco Free Ireland Programme

     Theme 2:
     Protection of children in all of our initiatives, denormalise tobacco use for the next generation and
     promote tobacco free environments.

              TFI Policy      Action Identified                                   Proposal for “HOW” this will be met

      2.1     7.1             The protection of children must be                  Work with Tusla to support the development of a
                              prioritised in all of the initiatives outlined in   policy for the protection of children from second hand
                              the policy.                                         smoke in foster care homes and all levels of care.

      2.2     7.5             Promote tobacco free campuses for all               Work with the DOH and a corporate partner to
                              healthcare governmental and sporting                develop a tobacco free campus toolkit for all types
                              facilities in consultation with key                 of workplaces.

                                                                                  Work with LCDCs and CYPSCs to promote tobacco
                                                                                  free public spaces and environments for children.

      2.3     7.2             Denormalisation must be a complimentary             Work with the Department of Education and Science
                              underpinning theme for all of the initiatives       and partners to develop the tobacco elements of the
                              within the policy.                                  revised SPHE junior cycle curriculum.

      2.4     7.2/7.5         Engage internally with CHOs/                        Engage with the Mental Health and Social
                              Hospital groups and externally with                 Care national offices to support the successful
                              relevant stakeholders to ensure that                implementation of the HSE TFC Policy.
                              denormalisation is a complementary
                              underpinning theme for all initiatives.

      2.4.1                                                                       Engage with HIQA and MH Commission in a formal
                                                                                  way to lobby for inclusion of TFCP as part of their
                                                                                  audit criteria.

HSE Tobacco Free Ireland Programme

Deliverables                                         Responsible                                    Timeframe
                                                                                             Commence     Complete

Engage with TUSLA to advocate that they prioritise   TFI Programme Team                      2019         2021
the development of a policy to protect children
from second hand smoke in all levels of care and
support them in this process.

Generic Tobacco Free online toolkit developed.       TFI Programme Team/DoH                  2018         2018

Guidance document developed for LCDCs to             TFI Programme Team                      2018         2018
promote tobacco free environments, promote
denormalisation and signpost to local cessation

Input provided at LCDC forums.                                                               2018         2021

Tobacco elements included in the SPHE junior         TFI Programme Team/SP&T Education       2018         2018
cycle curriculum.                                    Programme Manager

TFC targets set and agreed for each service area     TFI Programme Team/TFIPG                2018         2019
within each CHO/Hospital group.                      CHO Representative
                                                     Acute Service Representative/Mental
Implementation status monitored at service/          Health Representative/Social Care       2018         2021
operational level.                                   Representative

Guidance tools and resources for implementation                                              2018         2019
in specific service areas developed.

Workshops/conference/events planned & delivered                                              2018         2021
to support quality improvement/monitoring of TFC

HIQA/MH Commission supported to include TFC          TFI Programme Team/Quality              2018         2018
policy and the treatment of tobacco addiction as     Improvement
part of their audit criteria.

HSE Tobacco Free Ireland Programme

              TFI Policy      Action Identified                            Proposal for “HOW” this will be met

      2.4.2                                                                Work with HR to progress tobacco free Ireland

      2.4.3                                                                Develop a tobacco free campus policy communications
                                                                           campaign targeting service users the public and staff.

      2.4.4                                                                Work with Quality Improvement/Quality Assurance
                                                                           and Verification to progress and embed TFC policy
                                                                           in their routine audits and their quality improvement

      2.4.5                                                                Engage with National Estates Office to incorporate
                                                                           TFC policy provisions in the development of all new
                                                                           sites and buildings.

      2.5     9.5             Undertake a social marketing campaign        Communications to review social marketing campaign
                              (DOH funding dependent) focusing on the      developed in relation to second hand smoke (SHS).
                              risks to children from exposure to second-
                              hand smoke with particular reference to
                              smoking in cars.

      2.6                     Engage with partner agencies and youth       Work with partner agencies i.e. Spunout and ICS to
                              organisations to address tobacco control     develop targeted tobacco control programmes to
                              among youth.                                 support cessation/prevent initiation.

      2.6.1                                                                Review and publish ‘Quit 4 Youth’ training resources.

HSE Tobacco Free Ireland Programme

Deliverables                                           Responsible                                   Timeframe
                                                                                              Commence     Complete

HR representative nominated to TFIPG.                  SP&T/TFIPG/HR                          2019         2021
HR representatives to lead the revision of the         TFI Programme Team/HR/all divisions
National TFC Policy.
HSE tobacco free campus policy reviewed, revised
and signed off.
Communicate the revised policy to all levels of
management and staff.

Suite of TFC communication tools developed and         Communications/TFI Programme Team/     2019         2021
implemented.                                           CHOs/HGs

TFC is included in quality improvement practice/       TFI Programme Team/Quality             2020         2021
protocols.                                             Improvement/Quality A&V
TFC policy implementation is audited either
independently or is done as an integral part
of a service audit on a two year basis.

TFC policy provisions routinely incorporated in new    TFI Programme Team                     2019         2021
estate projects/public-private partnerships as part
of the tender process.

Communications will promote the SHS campaign           Communications                         2019         2021
through social media channels. A specific focus will
be given to the risks to children from exposure to

Tobacco content on Spun out website developed          TFI Programme Team/HP&I/Spun out/ICS   2018         2020
and monitored on an on-going basis.
Youth organisations supported to develop a youth
tobacco control advocacy forum.

Quit 4 youth reviewed and published.                   HP&I                                   2018         2018
Training programme to support resource developed                                              2019         2021
and training delivered.

HSE Tobacco Free Ireland Programme

     Theme 3:
     Legislative compliance and regulating the retail environment

              TFI Policy      Action Identified                                  Proposal for “HOW” this will be met

      3.1     8.2             Continue to promote compliance with all            Identify this action in the HSE Annual Service Plan.
                              provisions of the Public Health (Tobacco)
                              Act 2002 as amended particularly the
                              workplace legislation.

      3.2     8.3             Develop capacity within the HSE’s                  Enforcement, compliance levels & legislative
                              Environmental Health Service to maintain           provisions reviewed.
                              consistent and sustained enforcement of all        Non-compliant businesses/services targeted.
                              aspects of the tobacco control legislation.

      3.3     9.6             Monitor the effectiveness of the current           Joint DOH TACU and HSE group to review all
                              tobacco free legislation, including the review     tobacco control legislation quarterly.
                              of existing exemptions and the monitoring
                              of compliance with these provisions.

      3.4     8.4             Develop special investigation capacity             The reconfiguration of the Environmental Health
                              within the HSE’s Environmental Health              Service will consider this recommendation.
                              Service to assess compliance by tobacco
                              and E-cigarette manufacturers.

      3.5     9.19            Monitor the implementation of regulations          Joint DOH TACU and HSE group to review all
                              for pictorial warnings.                            tobacco control legislation quarterly.

      3.6     9.22            Review existing legislation to ensure that it is   Joint DOH TACU and HSE group to review all
                              fit for purpose to deal with new and emerging      tobacco control legislation quarterly.
                              measures and marketing programmes
                              adopted by the tobacco industry.

      3.7     9.28            Examine and monitor the existing tobacco           Joint DOH TACU and HSE group to review all
                              legislation to ensure that it is inclusive of      tobacco control legislation quarterly.
                              contemporary forms of communications.

HSE Tobacco Free Ireland Programme

Deliverables                                          Responsible                               Timeframe
                                                                                         Commence     Complete

Data to be inserted here.                             AND Environmental Health           2018         Annual

Annual review of national enforcement and             AND Environmental Health           2018         Annual
compliance levels completed.                                                                          2021
Standard operational protocols reviewed annually.

Convictions published quarterly on the HSE website.   AND Environmental Health           2018         Annual

Included as a composite part of the developing        AND Environmental Health           2018         Annual
National Tobacco Control Operational Unit.                                                            2021

Survey and report on combined warnings on a           AND Environmental Health           2018         Annual
cohort of cigarettes developed by revenue (illicit                                                    2021

Follow up of review of EU manufacture, presentation   AND Environmental Health           2018         Annual
and sale of tobacco and related products complete.                                                    2021
Regulations 2016 reviewed and amendments
proposed to DOH in order to satisfy the
requirements of directive 2014/40/EU.

Legislation reviewed quarterly.                       AND Environmental Health           2018         Annual

HSE Tobacco Free Ireland Programme

     Theme 4:
     Treat tobacco dependence as a health care issue

              TFI Policy      Action Identified                                  Proposal for “HOW” this will be met

      4.1     9.7             Identify a lead person with clear lines            TFI Programme lead to liaise with HP&I to identify
                              of responsibility for the coordination of          a lead for cessation services.
                              smoking cessation services within the health
                              service to ensure a national approach.

      4.2     9.8             Develop comprehensive national smoking             Complete an assessment of the delivery of tobacco
                              cessation guidelines. These to include the         cessation services in HSE and develop a model for
                              minimum level of service provision that each       service delivery.
                              service provider needs to have in place.

      4.3                                                                        Review existing national standards for the intensive
                                                                                 cessation support Programme and publish
                                                                                 renewed standards.

      4.4                     Develop Clinical Guidelines for the                Develop guidelines in line with NCEC processes
                              Identification Diagnosis & Treatment               and publish.
                              of Tobacco Dependence.

      4.4.1                                                                      TFI Programme Team to complete clinical guideline

      4.4.2                                                                      Establish a Clinical Guideline consultation group
                                                                                 within the HSE and externally.

      4.4.3                                                                      Prioritisation submission made by Guideline
                                                                                 Development Group to NCEC.

      4.4.4                                                                      Review existing national/international guidelines
                                                                                 and draft/adapt or amend for the Irish setting.

      4.4.5                                                                      Undertake extensive internal and external
                                                                                 stakeholder consultation.

      4.4.6                                                                      Amend guidelines post consultation and submit
                                                                                 to NCEC.

      4.4.7                                                                      Publish endorsed guidelines.

      4.5                     Develop Implementation and communication           Review national/international implementation plans
                              plan for the introduction of the final guideline   for other guidelines and draft/adopt or amend for
                              for the identification, diagnosis and treatment    the Irish setting.
                              of tobacco dependence into the clinical setting.

      4.6     9.11            Train all frontline healthcare workers to          Support the work of the MECC project team through:
                              deliver interventions for smoking cessation        active participation in MECC oversight group
                              as part of their routine work.                     and working groups; providing behaviour change
                                                                                 support tools and resources for smoking cessation.

                                                                                 Provide and agree content for MECC tobacco module.

HSE Tobacco Free Ireland Programme

Deliverables                                               Responsible                                    Timeframe
                                                                                                   Commence     Complete

Lead in Place.                                             HP&I AND                                2018         2018

Assessment of tobacco cessation service complete.          HP&I supported by TFI Programme Team    2019         2020
Model for service delivery for standard service and
for services targeted at special interest populations
drafted and signed off (Post publication of the Clinical
Guidelines for the Treatment of Tobacco Dependence).

Standards reviewed and published.                          HP&I supported by TFI Team              2019         2020

Clinical guidelines quality assured by NCEC,               TFI Programme Team/Clinical Guideline   2018         2020
published and endorsed by the DoH.                         Development Group

NCEC Clinical Guideline training completed by TFI          TFI Programme Team                      2018         2018
Programme Team.

Clinical guideline consultation group established          TFI Programme Team                      2018         2018
and convened.

Guidelines prioritised by NCEC.                            Clinical Guideline Development Group    2019         2018

Existing guidelines critically appraised and draft         Clinical Guideline Development Group    2019         2019
guideline complete.

Stakeholder consultation completed.                        Clinical Guideline Development Group    2019         2019

Guideline amended following stakeholder                    Clinical Guideline Development Group    2019         2019
consultation and submitted to NCEC.

Guideline quality assured by NCEC and endorsed             Clinical Guideline Development Group    2019         2020
by the DoH and Minister for Health.

Implementation and Communication plan drafted.             TFI Programme Team/Clinical Guideline   2019         2019
                                                           Development Group/Communications

Tobacco Knowledge Reference Group established.             HP&I                                    2018         2018

Participation in MECC oversight group.                     TFI Lead                                2018         2020

MECC tobacco module developed, piloted, amended            TFI Programme Team/HP&I                 2018         2018
and launched as part of MECC training suite.

HSE Tobacco Free Ireland Programme

              TFI Policy      Action Identified                            Proposal for “HOW” this will be met

      4.6.1                                                                Agree brief intervention training/MECC targets annually
                                                                           in consultation with oversight group and TFIPG.

                                                                           Continue to train health professionals in smoking



      4.7     9.9             Undertake targeted approaches for            Work with the Women and Infants Programme
                              specific groups (C2DE), particularly young   (W&IP) to develop and agree evidence based
                              people, lower socioeconomic groups,          tobacco control actions to be included in the
                              pregnant and post-partum women and           W&IP Action Plan.
                              patients with chronic disease disorders to
                              treat tobacco dependence.
                              Develop intensive cessation services which
                              target specific population groups:

      4.7.1                   Services targeting pregnant and post-        Work with the HI hospital group managers/Primary
                              partum women                                 Care and the Woman and Infants Programme to
                                                                           advocate for the establishment of onsite cessation
                                                                           services in maternity settings across Acute and
                                                                           Primary Care services.

      4.7.2                                                                Work with the chronic disease clinical lead/project
                                                                           manager for maternity system to advocate for risk
                                                                           recording to be included in the new maternity IT
                                                                           system (MN-CMS).

      4.7.3                                                                Work with Maternity services to bring about routine
                                                                           carbon monoxide monitoring (CO) and referral at
                                                                           specific antenatal contacts/visits.

      4.7.4                                                                Scope and deliver an action research project
                                                                           across primary care and acute maternity services
                                                                           to examine the effectiveness of routine CO
                                                                           monitoring and intensive cessation provision/
                                                                           Incentivised Quit.

HSE Tobacco Free Ireland Programme

Deliverables                                                  Responsible                                   Timeframe
                                                                                                     Commence     Complete

Targets agreed and included in NSP.                           HP&I and TFIPG                         2018         Annual

Health professionals trained to deliver brief interventions   HP&I                                   2018         Annual
for smoking cessation as part of MECC training.                                                                   2021

Tobacco content incorporated in to Chronic                    TFI Programme Team/HP&I/Clinical       2018         2019
Disease Prevention Module for all undergraduate/              Strategies and Programmes
postgraduate health professional courses.

Continue to train a variety of staff as intensive             HP&I                                   2018         2021
smoking cessation specialists.

Specific tobacco actions included in the W&IP                 TFI Programme Team/HP&I                2019         Annual
annual programme of work.                                                                                         2021

Establishment of new maternity onsite cessation               HP&I/TFI Programme Team/W&IP           2019         2021
services/referral pathways (funding dependant).
Provide guidance and training to maternity units to
establish services according to the HSE Standard
Treatment Programme.
Staff trained in MECC and in the specialist
cessation module for pregnancy.

Risk recording for tobacco prevalence and                     TFI Team/HP&I/CS&P, IT, OOCIO/W&IP     2018         2018
treatment included in MN-CMS.

Advocate for routine CO monitoring to be                      TFI Programme Team/HP&I                2019         2021
embedded in routine antenatal service.                        W&IP/CS&P
Maternity hospital networks supported to train
midwives in the completion of CO monitoring.

Business case complete and approved.                          W&IP/HGs/TFI Programme Team/HP&I       2019         2021
Project initiated and evaluated.

HSE Tobacco Free Ireland Programme

              TFI Policy      Action Identified                           Proposal for “HOW” this will be met

      4.7.5                   Services targeting smokers with Mental      Work with MH national office/CHOs to implement
                              ill-health                                  and monitor TFC policy in MH settings.
                                                                          Work with the Mental Health national office/CHOs/
                                                                          MH advocacy groups to advocate for and support
                                                                          the development of onsite smoking cessation services
                                                                          across acute and community mental health services.

      4.7.6                   Services targeting smokers in lower socio   Work with ICS to progress the implementation of
                              economic groups                             the ‘We Can Quit’ cessation programme targeting
                                                                          women in lower socio economic groups.



      4.7.9                                                               Review QUIT campaign to realign media buy
                                                                          to target more effectively specific hard to reach
                                                                          population groups.
                                                                          Continue to set specific targets and monitor
                                                                          throughput of hard to reach population groups to
                                                                          intensive cessation services through the NBSMS.

      4.8                     Services targeting smokers with existing    Explore with the Office of Nursing and Midwifery
                              chronic disease                             Services opportunities to progress nurse
                                                                          prescribing of tobacco dependence treatments.

      4.9                     Establish a national database for the       Develop and implement a Patient Management
                              collection and collation of data from all   System (NBSMS) for services to standardise data
                              smoking cessation services.                 collation and facilitate electronic referral to improve

HSE Tobacco Free Ireland Programme

Deliverables                                             Responsible                                        Timeframe
                                                                                                     Commence     Complete

Tobacco Free Campus policy implemented in all            Mental Health National Office/TFI           2018         2021
mental health settings.                                  Programme Team/HP&I
Routine monitoring of tobacco free campus and            CHO/HP&I
quality improvement processes established in MH.
New mental health onsite cessation services/             CHO/HP&I
referral pathways established.

Support delivery of the “We Can Quit” Programme          ICS, HP&I/Trinity/TFI Programme Team/       2018         2020
through HSE staff and sourcing suitable locations/       Communications
HSE venues.

Support the planning and running of a randomised         HP&I/TFI Programme Team                     2018         2021
cluster pilot trial of “We Can Quit”.

‘We Can Quit’ pilot trial complete and report drafted.   ICS, HP&I/Trinity                           2018         2020
                                                         TFI Team

QUIT campaign continually monitored to ensure it         Communications/TFIP team/ HP&I
is reaching specific population groups of interest.

Specific population group targets for intensive          TFIP team/HP&I/CHOs/Hospital Groups
cessation services set & NBSMS system monitored
to assess performance against targets.

Tobacco dependence treatments included in the            N&MS/TFI Programme Team/NMBI/               2020         2021
list of medications for chronic disease specialist       Clinical Guideline Development Group/
nurses.                                                  W&IP

Tender process complete.                                 TFI Programme Team                          2018         2019
Contract drafted and signed between HSE and              HP&I/Procurement
successful provider.                                     External Provider/HP&I/ Comms/Relate
IT system developed to the required specification.       Care
Pilot site identified to trial new system and one stop
referral model.
New system integrated in to existing IT systems in
acute divisions and Primary Care.
Amendments completed to system based on pilot
Three integrations delivered between the new
National Behavioural Support Patient Management
System; Healthlink, Quit.ie & the MN-CMS.
Communications plan developed to promote the one
stop referral model to GPs/PC/MH/SC/Acute staff.
New system launched and communicated.

HSE Tobacco Free Ireland Programme

     Theme 5:
     Monitor tobacco use and prevalence and evaluate effectiveness of all interventions

              TFI Policy      Action Identified                         Proposal for “HOW” this will be met

      5.1     9.2/9.3         Tobacco control measures should be        On-going surveillance of tobacco use through
                              continuously evaluated to ascertain       HSE Tracker Survey, Healthy Ireland and Health
                              impacts and outcomes.                     Behaviour in School Children Surveys.
                                                                        Publish first and second HSE State of Tobacco
                                                                        Control Report.

      5.1.1                                                             Work with services/divisions to agree targets for
                                                                        completion of GNTH global online self-audit.

      5.2     9.20/9.3        Tobacco control measures should be        Evaluation built in to the QUIT campaign and
                              continuously evaluated to ascertain       cessation service provision and carried out as
                              impacts and outcomes including the        appropriate.
                              evaluation of campaigns and programmes.

      5.2.1                                                             Work with quality improvement and quality
                                                                        assurance and verification division to progress
                                                                        quality improvement in terms of TFCP
                                                                        implementation and the treatment of tobacco
                                                                        dependence. See Action 8.3/8.4/9.19/9.28.
      5.2.2                                                             Evaluation of cessation/Quit services.
                                                                        Monitor throughput, reach of tobacco users
                                                                        through National Health Behavioural Management
      5.2.3                                                             Evaluation of BISC training effectiveness.

HSE Tobacco Free Ireland Programme

Deliverables                                          Responsible                                  Timeframe
                                                                                            Commence     Complete
Secondary analysis of tobacco indicators from         TFI Programme Team/Public Health/     2018         2018
HI survey, HBSC and TILDA published to build          Health Information Unit
evidence for TFI.
State of Tobacco Control in Ireland Report                                                  2018         2021
produced in 2018 and 2021.
Develop and publish HSE tobacco control research                                            2019         2021
and information plan (2019.)
Implement HSE tobacco control research and                                                  2019         2021
information plan (2020-2021).
Targets for GNTH self-audit drafted and embedded      TFI Programme Team/CHOs/Hospital      2018         2021
in CHO/Hospital Group Healthy Ireland Plans.          Groups
Annual collation of data on the number of self-
audits completed.
Completion of monthly evaluation of digital display   Communications/HP&I/TFI Programme     2018         On-going -
media.                                                Team                                               2021
Completion of quarterly web statistics using
Google analytics.
Completion of You-tube tracking.
Quarterly analysis of conversion rates from digital
Completion of quarterly and annual audit on media
Completion of Quarterly tracking of media
coverage measurements.
Completion of monthly audit of cessation service
provision against target.
Completion of omnibus research awareness to
monitor campaign awareness and effectiveness.
Completion of monthly evaluation of social media
Quality improvement guidance received on TFC          TFI Programme Team/HP&I               2019         2020

Monthly performance reports on throughput and         HP&I/Communications/TFI Programme     2018         2021
reach of cessation services drafted.                  Team/ICT

BI training evaluation complete and report            TFI Programme Team                    2018         2018

HSE Tobacco Free Ireland Programme

     Appendix A
     Tobacco Free Ireland                                     Programme Team (2018)
     Programme Group (TFIPG)                                   Role                         Name
     An Implementation Group entitled the “Tobacco             National Lead                Martina Blake
     Free Ireland Programme Group” (TFIPG) has
                                                               Project Manager              Edward Murphy
     been set up under the Tobacco Free Ireland
     Programme, chaired by Ms. Martina Blake,                  Tobacco Free Campus          Miriam Gunning
                                                               Policy Lead
     Tobacco Free Ireland Programme Lead. The
     group has clear terms of reference which will             Administrator                TFI@hse.ie
     provide strategic direction for the work of the           Clinical and Research Lead   Dr Paul Kavanagh
     Programme, monitor progress and facilitate
                                                               Communications Campaign      Aoife O’ Sullivan
     effective co-operation between service areas.             Manager                      Rachel Wright
     Membership of the implementation group includes
     senior management from each HSE service area,
     the Hospital Groups and Community Healthcare
     Organisations who have responsibility for the
     delivery of agreed actions within their respective
     services at both a national and local level.

     Tobacco Free Ireland Programme Group (TFIPG) Membership
      Service Areas Represented 2018
      National Lead, Tobacco Free Ireland Programme
      Project Manager, Tobacco Free Ireland Programme
      Tobacco Free Campus Policy Lead, Tobacco Free Ireland Programme
      Clinical and Research Lead, Public Health/Tobacco Free Ireland Programme
      HSE Communications
      Health Promotion and Improvement National Office
      Healthy Ireland National Office Lead
      HSE Human Resources
      Social Care – Disability Services
      Social Care – Older Persons Services
      Mental Health
      Primary Care
      National Acute Hospitals Office
      Hospital Groups
      Community Healthcare Organisations
      Environmental Health
      National Behavioural Support Management System Project Manager
      National Cancer Control Programme

HSE Tobacco Free Ireland Programme

Appendix B
Tobacco Free Ireland                                    Tobacco Free Ireland Partners
Partners Group                                          Group Membership
Partnership Working/Stakeholder Involvement             Alpha 1 Foundation Tobacco Free Ireland
                                                        Programme, HSE (Chair)
Healthy Ireland places significant emphasis
                                                        ASH Ireland
on collaboration and partnership working.
                                                        Asthma Society of Ireland
The achievement of our strategic priorities is
dependent on effective partnerships internally and      Athlone Institute of Technology
strong cross-sectoral engagement with external          Communications, HSE
stakeholders. In some instances other agencies
                                                        COPD Ireland
and government departments are better placed to
deliver on actions which impact on people’s health      Environmental Health, HSE
and wellbeing – we must proactively leverage            Health Promotion and Improvement, HSE
existing relationships and forge new relationships      Institute of Public Health
in pursuit of our shared agenda.
                                                        Irish Cancer Society
The Tobacco Free Ireland Partners Group is a multi-     Irish College of General Practitioners
agency partnership made up of representatives
                                                        Irish Dental Association
from across non-government organisations with an
interest in Tobacco control. The aim of the group       Irish Heart Foundation
is to provide a formal platform for discussion and      Irish Thoracic Society
dialogue between the HSE and non-governmental           National Cancer Control Programme
stakeholders on tobacco control. Ideas and best
                                                        National Women’s Council of Ireland
practice can be shared in relation to tobacco
control issues. This multi-agency working group will    Pharmaceutical Society Of Ireland
also help drive, co-ordinate and support the delivery   Public Health, HSE
of the priorities in the Tobacco Implementation Plan.   Royal College of Physicians Ireland
                                                        Tobacco Free Research Institute

HSE Tobacco Free Ireland Programme

     An Assessment of the Economic Cost of Smoking
     in Ireland, ICF International, 2016.

     Healthy Ireland in the Health Services National
     Implementation Plan 2015 – 2017, Health Service
     Executive, 2015.

     Healthy Ireland Survey 2017: Summary of
     Findings, IPSOS MRBI, 2017.

     Tobacco Free Ireland: Report of the Tobacco
     Policy Review Group, Department of Health, 2013.

     Youth Smoking in Ireland: A special analysis of the
     Health Behaviour in School-aged Children (HBSC)
     Study, Health Service Executive, 2018.

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